Provider Demographics
NPI:1497206221
Name:ITHACA ALPHA HOUSE CENTER, INC.
Entity Type:Organization
Organization Name:ITHACA ALPHA HOUSE CENTER, INC.
Other - Org Name:CAYUGA ADDICTION RECOVERY SERVICES RESIDENTIAL PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OAKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-387-5535
Mailing Address - Street 1:PO BOX 724
Mailing Address - Street 2:38 E MAIN ST.
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-0724
Mailing Address - Country:US
Mailing Address - Phone:607-387-5535
Mailing Address - Fax:607-387-5526
Practice Address - Street 1:6621 NYS ROUTE 227
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-0724
Practice Address - Country:US
Practice Address - Phone:607-387-5535
Practice Address - Fax:607-387-5526
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ITHACA ALPHA HOUSE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171212037324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01292828Medicaid